• Ching-Jen Chen, Dale Ding, Cheng-Chia Lee, Kathryn N Kearns, I Jonathan Pomeraniec, Christopher P Cifarelli, David E Arsanious, Roman Liscak, Jaromir Hanuska, Brian J Williams, Mehran B Yusuf, Shiao Y Woo, Natasha Ironside, Ronald E Warnick, Daniel M Trifiletti, David Mathieu, Monica Mureb, Carolina Benjamin, Douglas Kondziolka, Caleb E Feliciano, Rafael Rodriguez-Mercado, Kevin M Cockroft, Scott Simon, Heath B Mackley, Samer Zammar, Neel T Patel, Varun Padmanaban, Nathan Beatson, Anissa Saylany, John Lee, and Jason P Sheehan.
• Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia.
• Neurosurgery. 2021 Jan 13; 88 (2): 313-321.

BackgroundPrior comparisons of brain arteriovenous malformations (AVMs) treated using stereotactic radiosurgery (SRS) with or without embolization were inherently flawed, due to differences in the pretreatment nidus volumes.ObjectiveTo compare the outcomes of embolization and SRS, vs SRS alone for AVMs using pre-embolization malformation features.MethodsWe retrospectively reviewed International Radiosurgery Research Foundation AVM databases from 1987 to 2018. Patients were categorized into the embolization and SRS (E + SRS) or SRS alone (SRS-only) cohorts. The 2 cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was defined as AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiologic and symptomatic radiation-induced changes (RIC), and cyst formation.ResultsThe matched cohorts each comprised 101 patients. Crude AVM obliteration rates were similar between the matched E + SRS vs SRS-only cohorts (48.5% vs 54.5%; odds ratio = 0.788, P = .399). Cumulative probabilities of obliteration at 3, 4, 5, and 6 yr were also similar between the E + SRS (33.0%, 46.4%, 56.2%, and 60.8%, respectively) and SRS-only (32.9%, 46.2%, 56.0%, and 60.6%, respectively) cohorts (subhazard ratio (SHR) = 1.005, P = .981). Cumulative probabilities of radiologic RIC at 3, 4, 5, and 6 yr were lower in the E + SRS (25.0%, 25.7%, 26.7%, and 26.7%, respectively) vs SRS-only (45.3%, 46.2%, 47.8%, and 47.8%, respectively) cohort (SHR = 0.478, P = .004). Symptomatic and asymptomatic embolization-related complication rates were 8.3% and 18.6%, respectively. Rates of post-SRS hemorrhage, all-cause mortality, symptomatic RIC, and cyst formation were similar between the matched cohorts.ConclusionThis study refutes the prevalent notion that AVM embolization negatively affects the likelihood of obliteration after SRS.Copyright © 2020 by the Congress of Neurological Surgeons.

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